Breadcrumb

DHS OIG FY 2012 Annual Report

To Governor Pat Quinn and Members of the Illinois General Assembly:

In accordance with Section 1-17 of the Illinois Department of Human Services Act (20 ILCS 1305) and the Abuse of Adults with Disabilities Intervention Act (20 ILCS 2435/5), I am pleased to submit the Fiscal Year (FY) 2012 report of the Office of the Inspector General (OIG) in the Department of Human Services (DHS), entitled Abuse and Neglect of Adults with Disabilities.

This OIG has the statutory mission of investigating and reporting upon allegations of abuse and neglect of adults who have disabilities and who reside in private homes, in DHS-operated MH and DD facilities, and in programs operated by local community agencies that are licensed, certified or funded by DHS to provide mental health or developmental disability services.

This annual report provides an overview of OIG's work during FY2012. It covers OIG's training, unannounced facility site visits, investigations, recommendations to prevent recurrence, referrals for services, reviews to ensure implementation of corrective actions, and other aspects of OIG's statutory mission.

The report reflects the continued increase in allegations of abuse or neglect of adults with disabilities in the community. Over the past two fiscal years, OIG has seen a 23% decrease in allegations in DHS facilities, a 17% increase in allegations involving community agency programs and a 34% increase in allegations in domestic settings. As services continue to shift from facilities to the community, OIG expects these trends will continue.

Through its facility investigators and community operations, OIG is committed to addressing instances of abuse and neglect of Illinois' residents who are facing mental and physical challenges.

Sincerely,

Daniel Dyslin
Acting Inspector General

Executive Summary

During FY2012, the Office of the Inspector General (OIG) accomplished the following:

Presented 102 training sessions on reporting or investigating abuse or neglect, with a total of 1,999 participants.

Received 3,463 abuse/neglect allegations - 15% more than during FY2011. Compared to FY2011, OIG received:

5% more allegations at facilities,

14% more allegations at community agencies, and

28% more allegations in domestic settings.

Referred 548 complaints that were outside OIG jurisdiction to the appropriate entity, as well as recording an additional 1,412 calls that needed no referral.

Completed 3,420 investigations into abuse/neglect allegations - 11% more than during FY2011 and 20% more than during FY2010. OIG completed those 3,420 investigations in an average of 48.0 days per case, compared to the goal of 60 days.

Closed 3,398 investigations into abuse/neglect allegations - 11% more than during FY2011 and 18% more than during FY2010. OIG substantiated abuse or neglect in 493 of those investigations. Domestic cases accounted for 134 of the 493 substantiated cases and facility/agency cases for the other 359.

Received 153 reports of deaths of individuals who were or had been receiving services in facility or community agency programs. OIG closed 165 death cases during FY2012. Of the 165 closed death cases, abuse was substantiated in one case and neglect in five. Issues were identified in 22 other cases.

Recommended administrative action in 842 cases at facilities or community agencies during FY2012-10% more than FY2011 and 14% more than FY2010. OIG received DHS-approved written responses in 828 of those cases, as well as another 66 completed in prior years, for a total of 894 written responses, which identified 1,326 issues, the most common being substantiated abuse/neglect.

Referred to the IDPH Healthcare Worker Registry 64 employees of facilities or community agencies for substantiated physical abuse, sexual abuse, or egregious neglect. The Health Care Worker Registry is maintained by the Illinois Department of Public Health.

Chapter I: Preventing Abuse/Neglect

A. Quality Care Board

The Quality Care Board was authorized in 1992 by Public Act 87-1158, which states that the Board's purpose is to "monitor and oversee the operations, policies, and procedures" of the Office of the Inspector General (OIG). The Board is empowered to provide consultation on OIG practices, to review regulations, to advise on training, and to recommend policies to improve intergovernmental relations.

The law provides for the Board to have seven members, each appointed by the governor with consent of the State Senate. The members must be qualified by professional knowledge or experience in law, investigatory techniques, or the care of people who have mental illness or developmental disabilities. At least two members must either have a disability themselves or have a child with a disability. The members are not paid, but OIG may reimburse them for any costs for travel.

Due to the resignations of a few members, the Quality Care Board finished FY2012 with only

four members*:

Rita Ann Burke of Makanda, Chair;

Ed Baker of Coal City;

Thane Dykstra of Joliet; and

Brian Neal Rubin of Buffalo Grove.

The Board's quarterly meetings in FY2012 were held by teleconference on July 19, 2011, October 13, 2011, January 17, 2012 and June 14, 2012.

*In early FY2013, the Board was re-constituted and now includes 6 members.

B. Unannounced Site Visits

OIG is statutorily mandated by the Department of Human Services Act (20 ILCS 1305/1-17) to conduct annual unannounced site visits to the DHS facilities providing developmental disability or mental health services. The site visits are part of the statutory mission of OIG to prevent abuse and neglect.

The site visits seek to cover a wide range of activities, initiatives, and potential problem areas related to abuse and neglect. Each year, unique issues are identified for site visits. These issues are reviewed with the goal of providing actionable feedback that will allow the facilities to take steps to prevent abuse and neglect in the future.

Site Visit Dates

In FY2012, each OIG site visit was conducted by a team of one to three OIG staff, one of whom is a registered nurse. The dates of the site visits were as follows:

Alton MHC: October 18-19, 2011

Chester MHC: March 7-8, 2012

Chicago-Read MHC: October 5-6, 2011

Choate DC: March 5-6, 2012

Choate MHC: March 6-7, 2012

Elgin MHC: November 18-19, 2011

Fox DC: February 22, 2012

Jacksonville DC: March 26-27, 2012

Kiley DC: December 6-7, 2011

Ludeman DC: January 4-5, 2012

Mabley DC: July 20-21, 2011

Madden MHC: August 24-25, 2011

McFarland MHC: November 1-2, 2011

Murray DC: September 7-8, 2011

Shapiro DC: September 21-22, 2011

Singer MHC: August 2-3, 2011

Tinley Park MHC: March 27, 2012

To reduce the travel costs associated with the site visits, OIG sent a preliminary request for documents (e.g., relevant policies). OIG batched these requests, sending them out to at least three facilities at a time, so that no facility was forewarned about the date of the site visit. In addition to reducing the travel costs to OIG, receiving these documents in advance also lessens the site visit's interruption of facility operations.

Each site visit began with an entrance conference, where the site visitors introduced themselves, provided an explanation of the site visit plan, and identified the administrative staff to be interviewed. The OIG site visit team reviewed relevant documentation and interviewed administrative personnel, as well as direct care staff on the units, to discuss the issues and see the processes in place.

Each site visit then ended with an exit conference, where the overall findings of the site visit were presented. A formal report of the findings was provided to the facility within 60 working days of the site visit. The facility was asked to send OIG a copy of any written plan the facility might develop to address the report's recommendations within 60 days of the site visit's closure. Receiving this written plan assists OIG in planning the following year's site visit, as OIG will be following up on the facility's actions in response to the recommendations made the prior year.

2012 Site Visit Survey Topics:

Admitting/Annual Physical

Injury Reporting

Program Effectiveness

Deaths within 14 days of Discharge/Transfer

Maladaptive Sexual Behavior

Staff Use of Personal Cell Phones

EAP/PSP Accessibility

In FY2012, OIG made 22 site visit recommendations. Five of the 22 were repeat recommendations from FY2011. While individual facilities received recommendations, no systemic patterns or findings were identified. Staff who participated in the site visits demonstrated a willingness to address issues that may lead to abuse or neglect, and the support of the facility administration and the division was evident in each site visit.

C. Training

OIG has always been committed to training as a primary means to prevent abuse/neglect and to ensure reporting, investigating, and corrective action is taken when abuse/neglect is alleged to have occurred. OIG continually strives to update its training presentations and to add additional training topics to its schedules to further accomplish this goal. The statute has long mandated basic training of all facility and community agency employees on identifying and reporting abuse/neglect. Rule 50 requires that facilities and community agencies provide basic training to all full- and part-time employees, which includes owners/operators, contractors, subcontractors, and volunteers at least biennially.

FY2012 Training

The OIG conducts three primary trainings which are offered to facility and agency staff. The first and most popular course is Rule 50 training. This training instructs attendees on the overall function of OIG with emphasis on the definitions and reporting requirements of required reporters. Employees are required to be trained upon hire and at least biennially thereafter. In FY2012, OIG conducted forty-eight (48) Rule 50 trainings throughout the State with an attendance of 1,518 people. This is a 37% increase in trainings over FY2011 and nearly double (a 98% increase) the number of attendees.

The second OIG-conducted course, "Basic Investigative Skills," is a two-day course concentrating on all aspects of conducting an investigation, with a special emphasis on allegations involving persons with developmental disabilities or mental illness. OIG mandates this course at least once for every facility or community agency staff person who is approved to conduct investigations. During FY2012, OIG conducted twenty-three (23) Basic Investigative Skills classes with a total of 179 attendees.

The third course, "Investigative Skills Refresher," is a one-day refresher for individuals who have completed the first two courses within the past two years. It reviews the definitions and emphasizes the key points in conducting an investigation and discusses problem areas that the investigators may have experienced in the past two years. During FY2012, OIG conducted 31 Investigative Skills Refresher classes with a total of 302 attendees.

In addition to the three primary trainings, the Training Department provides training to OIG staff in a wide range of topics to meet their required fiscal year goal of five (5) continuing education training hours. Some of the training topics provided this fiscal year were: "A Question of Understanding: A Look at DD; Excel 2007; Forensic Interview, Parts 1 and 2; Intellectual Disability; and Word 2007. In FY2012, OIG staff were 100% compliant in meeting their annual training requirements.

D. Facility Staffing Ratios

By law, OIG's annual report must include facility census figures - that is, counts of the number of individuals receiving services in each facility - and the ratios of direct care staff to those individuals. OIG has always presented that ratio as of June 30th, which is the last day of each fiscal year.

Tables 1a and 1b (on following page) show the census figures and ratios for each type of facility for FY2012. The tables present census figures three ways:

Counting every individual only once, regardless of the number of times he or she is admitted during the year, give an "unduplicated count." This count is in the first column.

A more detailed way is to count every day that those individuals are in the facility or on temporary transfer to another location; this is the "person-days" or "on-books bed-days." This count is given in the second column.

The third column of counts is a simple census taken on June 30, 2012; that is, the number of individuals actually in the facility on that day.

That census figure taken on June 30, 2012, is the one used to calculate a direct care staff to patient ratio. The number of direct care staff is counted in Full-Time Equivalents, which counts part-time staff as only a fraction. That count, again as of June 30, 2012, is shown in the fourth column of the tables.

The June 30th census figures are then divided by the June 30th direct care staff figures to calculate a direct care staff to patient ratio, which is given in the fifth column.

E. Investigative Protocols

Rule 50 mandates that facilities and community agencies take some initial steps in response to allegations of abuse or neglect. Most importantly, they are to ensure the health and safety of involved individuals and staff, including ordering medical examinations when applicable. They are also to secure the scene and preserve evidence. If the allegation is of abuse, the facility or community agency must also remove the accused staff from having contact with any individuals pending the outcome of the investigation when there is credible evidence which supports the allegation.

Beyond these initial steps, the facility or community agency may take no other investigative steps without the permission of OIG or a criminal investigating entity. The facility or community agency may take administrative actions it deems necessary, but it must request permission from OIG before conducting its own investigation.

OIG may assign the full investigation to a community agency only if the agency has been through the investigative authorization process. This process is an effective way to obtain commitments by the agency or facility to investigate objectively, to avoid any appearance of a conflict of interest, and to designate specific employees as investigators.

The facility or community agency must first adopt OIG's Investigative Protocol - there is one for facilities and one for community agencies - and then apply to OIG for authorization. The application must include the names and job functions of the persons designated to be the OIG Liaison and investigators, including an assurance these persons have no conflict of interest in conducting investigations.

To approve a designated person as an investigator, OIG reviews his or her position title and job functions for any possible conflict of interest. OIG also verifies that the person has attended OIG-conducted investigative skills training within the past two years and has no substantiated cases against him/her.

Once OIG approves a facility or community agency's application, the designated investigators have additional responsibilities in every allegation. Specifically, unless otherwise directed by OIG, a designated investigator must do the following: Secure the scene and all possible evidence; identify and separate possible witnesses; conduct initial interviews of persons involved where necessary; and photograph the scene, evidence, and any injuries. Again, no further investigative steps may be done until allowed by OIG or the investigating agency.

OIG may then assign the full investigation to the community agency, but only in allegations of mental abuse, financial exploitation valued under $300, or neglect that is not alleged to be egregious. When an investigation is assigned to a community agency, however, OIG remains involved by assigning an OIG investigator to monitor and assist with the investigation. This monitoring investigator sends an investigative plan to follow, remains available to provide guidance, and is responsible for the first-level review of the final investigative report.

Renewal of an approved agency or facility investigative protocol is not automatic. An application must be submitted each year: Community agency authorizations are for a fiscal year; facility authorizations are for a calendar year. OIG considers the performance of the agency or facility when determining whether to renew the authorization. In June of 2012, the Inspector General's Office elected to change the authorization date to a calendar year basis for both agencies and facilities. An extension for existing community agency protocols was granted to cover the time frame of July 1, 2012 through December 31, 2012.

FY2012 Community Agency Investigative Authorizations

In June, 2011, OIG distributed an email to all 362 community agencies providing services within OIG's investigative jurisdiction. The email included a letter from the Inspector General providing an overview of the annual authorization process and links to three websites: The investigative protocol; the annual application form; and the OIG training calendar.

Ultimately, a total of 130 community agencies applied and were authorized by OIG for FY2012. A total of 644 agency employees were designated and approved as investigators.

CY2012 DHS-Operated Facility Investigative Authorizations

In November 2011, OIG distributed an email to the sixteen State-operated mental health or developmental disability facilities. By January 1, 2012, OIG authorized all sixteen facilities to assist with investigations. Each facility designated an OIG liaison and 128 employees were designated and approved as facility investigators.

Chapter II: Reporting Abuse/Neglect

OIG maintains a 24-hour Hotline, to receive reports of alleged abuse/neglect and to respond immediately, if needed. The Hotline also allows facilities and community agencies to meet the statutory four-hour time frame for reporting.

The Hotline receives reports of deaths, including when the death occurs within fourteen days after discharge or transfer elsewhere. If abuse or neglect is suspected, the death must be reported to OIG within four hours and OIG will conduct a full investigation.

A. Reporting Policies

Rule 50.20(d) mandates that all community agencies and facilities have a local policy detailing procedures for reporting abuse/neglect allegations and deaths. Thus, OIG reviewed all community agency and facility abuse/neglect reporting policies.

As of June 30, 2012, OIG received 317 community agencies' policies on reporting abuse and neglect. Of these policies, 312 were deemed acceptable, and OIG was having ongoing discussions with the other five agencies to address issues identified in their policies.

B. Non-Reportable Complaints

The OIG Hotline receives some calls about incidents or complaints that do not meet the abuse or neglect definitions or other reporting requirements in Rule 50 or Rule 51. The Hotline investigator explains why it is not reportable to OIG and, if applicable, may either refer or directly transfer the caller to the correct reporting entity.

Referrals

Issues that need follow-up, but are not within OIG's jurisdiction, need to be referred to the most appropriate entity. OIG may make the referral itself or instruct the caller on where and how to report the allegation.

Table 3 below shows the referral locations for Non-Reportables received this fiscal year.

Table 3: Referrals of Non-Reportable Complaints Received in FY2012

Referral Location

Non-Reportable
Facility or Agency Complaint

Non-Reportable Domestic

Setting Complaint

Local community agency or facility

267

20

Illinois Department of Public Health

37

11

Department of Children and Family Services

11

8

Local law enforcement authority

15

39

Department on Aging

0

23

DHS Division of Rehabilitation Services

3

24

DHS - BALC *

6

0

DHS Division of Developmental Disabilities

25

10

DHS Division of Mental Health

2

4

Illinois State Police

5

0

Other

18

20

None needed

1,006

406

Totals

1,395

565

Frequently, Non-Reportables are calls by a representative of the community agency or facility, self-reporting an issue or incident that is not reportable, in which case OIG instructs the caller to handle it internally and to call OIG back if any indication of abuse or neglect is found. Individuals may also call in Non-Reportables that can be referred back to the facility or community agency. Between both of these types of Non-Reportables, 19% of referrals in FY2012 were referrals back to the facility or agency.

In domestic allegations as well, a community agency may already be providing services and would be in the best position to determine what additional services may be needed. During FY2012, OIG referred to a local community agency about 3.5% of Non-Reportables involving individuals in domestic settings.

In FY2012, 1,412 calls needed no referral at all. For facility or community agency cases, the reason is most often a duplicate call or a complaint of an issue already resolved. Similarly, with domestic complaints, the most common were a resolution of the problem: That is, the alleged victim had already taken steps to seek help for the problem, such as changing caregivers; or the alleged victim's situation had already been resolved, such as moving to a different residence or getting a different guardian.

C. FY2012 Reporting

During FY2012, OIG received a total of 3,463 allegations of abuse or neglect. The counts by type and location are shown in the table below. Financial exploitation is included in abuse, as defined in Rule 50. Tables 5a through 5c, on the following pages, show a more detailed breakout by allegation type and location.

Table 4: Summary of Allegations Received by OIG in FY2012

Location

Abuse allegations

Neglect allegations

Total allegations

DHS-operated facilities

609

137

746

Community agencies

1,145

608

1,753

Domestic settings

459

505

964

Total

2,213*

1,250

3,463

*Contains the following financial exploitation allegations: five in DHS-operated facilities, 65 from Community agencies, and 64 from Domestic settings.

Overall, allegations reported to OIG continue to increase from year to year. Allegations increased overall by 15% since FY2011. The most significant increase since last year has been in the domestic setting at 28%, secondly in the community agencies at 14% and thirdly in facilities at 5%. However, if you compare total allegations in FY2012 to those in FY2010, there has been a 34% increase in domestic setting allegations, a 17% increase in community agency allegations, and a 30% decrease in facility allegations.

Allegations of abuse/neglect at the community agencies comprise the largest percentage of total allegations of any setting over the past several years. In FY2012, allegations at community agencies accounted for a little more than half (51%) of all allegations OIG received. This high percentage of allegations is reflective of the growing number of individuals receiving services by community agencies and the increase in education concerning reporting requirements provided to community staff.

Facilities

During FY2012, OIG received 609 allegations of abuse at the DHS facilities, including five allegations of financial exploitation. OIG also received 137 allegations of neglect at facilities.

The number of total allegations decreased by 13% from FY2009 to FY2012. Abuse allegations decreased by nearly 17%, but neglect allegations increased by 12% to 137 allegations.

Community agencies

During FY2012, OIG received 1,145 allegations of abuse, of which 65 were allegations of financial exploitation at community agencies. OIG also received 608 allegations of neglect at the community agencies during the fiscal year.

Combined allegations of abuse and neglect have increased by 14% at community agencies since FY2011. Since FY2011, allegations of abuse have risen 8% and allegations of neglect have risen 26%. This large increase is most likely due to the increased number of individuals receiving services in community agencies and the increased awareness of reporting.

Domestic

OIG's jurisdiction in domestic settings began in FY2001 and is limited to individuals between the ages of 18 and 59 who have a physical or mental disability that prevents them from seeking assistance on their own. Thus, OIG receives only a part of all complaints of abuse, neglect, or financial exploitation in domestic settings.

During FY2012, OIG received 964 allegations in domestic settings, which included 505 allegations of neglect, 459 allegations of abuse of which contained 64 allegations of financial exploitation. Total allegations increased by 28% from FY2011 and 34% from FY2010. The reason for this increase is because more people are aware of ADDAP and how to phone in complaints of abuse or neglect. More calls are also being received from hospital social workers, paramedics, and law enforcement as awareness increases.

Allegation Type

The tables on the following pages show the allegations and deaths that OIG received during FY2012 by type of allegation and program location. The tables list facilities individually and, at mental health facilities, separate "forensic" units (those for individuals who are committed by a criminal court order) from "civil" units (all others).

Allegations and deaths reported about community agencies are grouped into residential programs like community integrated living arrangements (CILAs) and non-residential programs like developmental training programs.

During FY2012, 153 deaths of individuals who were or had been receiving services in facility or community agency programs were reported to OIG. OIG closed 165 death cases during FY2012. Of the 165 closed death cases, abuse was substantiated in one, neglect was substantiated in five, and 22 other cases were unsubstantiated or unfounded with issues identified.

Table 5a: Allegations and Deaths Received in FY2012, Mental Health Services Only

Location

Physical abuse

Sexual abuse

Mental abuse

Financial exploitation

Neglect

Total received

Death reports

Facilities

Alton MHC (civil) 1

21

7

19

0

7

54

0

Alton (forensic) 2

25

9

16

0

9

59

0

Chester MHC

81

6

29

0

10

126

1

Chicago-Read MHC

3

0

11

0

6

20

1

Choate MHC

24

4

23

0

6

57

1

Elgin MHC (civil)

8

4

4

0

10

26

1

Elgin (forensic)

7

12

16

1

7

43

2

Madden MHC

24

2

14

0

7

47

1

McFarland MHC (civil)

11

4

4

0

4

23

0

McFarland (forensic)

4

0

5

0

0

9

0

Singer MHC

5

3

6

0

2

16

0

Tinley Park MHC

6

2

1

0

4

13

0

Facility subtotals

219

53

148

1

72

493

7

Community agencies

Residential sites

15

1

26

9

11

62

17

Non-residential sites

11

11

19

10

4

55

1

Agency subtotals

26

12

45

19

15

117

18

Rule 50 MH totals

245

65

193

20

87

610

25

1 Civil units are for those individuals not committed by criminal court order.

2 Forensic units are for those individuals who are committed by a criminal court order.

Table 5b: Allegations and Deaths Received in FY2012, Developmental Services Only

Location

Physical abuse

Sexual abuse

Mental abuse

Financial exploitation

Neglect

Total received

Death reports

Facilities

Choate DC

22

1

11

0

14

48

2

Fox DC

2

0

0

2

8

12

3

Jacksonville DC

39

5

9

0

10

63

3

Kiley DC

13

0

0

0

7

20

0

Ludeman DC

25

0

4

2

8

39

4

Mabley DC

3

0

1

0

5

9

0

Murray DC

21

0

0

0

8

29

4

Shapiro DC

23

0

5

0

5

33

4

Facility subtotals

148

6

30

4

65

253

20

Community agencies

Residential sites

465

38

219

41

461

1224

103

Non-residential sites

172

25

78

4

132

411

5

Agency subtotals

637

63

297

45

593

1635

108

Rule 50 DD totals

785

69

327

49

658

1,888

128

Table 5c: Allegations Received in FY2012, Domestic Settings Only

Disability Type

Physical abuse

Sexual abuse

Mental abuse

Financial exploitation

Neglect

Total received

Developmental disability

237

28

34

29

320

648

Mental health

29

1

3

18

56

107

Physical disability

49

3

11

17

129

209

Rule 51 totals

315

32

48

64

505

964

D. Initial Reporting Timeliness

OIG monitors new intakes for timeliness in allegations reported to OIG by staff of the community agency or facility where the alleged abuse/neglect occurred; this is called a "self-report" (does not apply to domestic cases). If an allegation is reported late, the database will flag the intake as late reporting. Then, the field investigator will investigate as to why it was late. If it was late, the final investigative report will cite the agency or facility for late reporting, and the Written Response will list it as needing corrective action.

Each month, OIG sends the DHS program divisions two reports - one of reporting by community agencies, and one of reporting by facilities. These reports show how many "self-reports" were reported to OIG late and what percentage were late; for each late intake, the reports show how many days it was late. The table below provides this information for the past eight fiscal years.

Table 2: Late Reporting by Program and Disability Type, FY2005 through FY2012

Fiscal Year

Total Self-Reports*

Late from Agencies

DD

Late from Agencies

MH

Late from Facilities

DD

Late from Facilities

MH

Total Late

Percent Late

FY2005

1,419

18

14

24

31

257

18.1

FY2006

1,514

186

24

35

16

261

17.2

FY2007

1,603

174

27

24

29

254

15.8

FY2008

1,642

185

32

18

24

259

15.8

FY2009

1,909

172

17

16

20

225

11.8

FY2010

2,033

163

15

33

21

232

11.4

FY2011

1,923

185

19

24

14

242

12.6

FY2012

2,144

199

17

25

22

263

12.3

*Reported to OIG by the facility or community agency itself.

FY2012 showed the highest number of self-reports to date. The number of self-reports increased by 11.5% from the previous year and the percentage of late reporting remained relatively the same.

Chapter III: Investigating Abuse/Neglect

OIG's primary statutory mission is to investigate allegations of abuse or neglect of individuals receiving mental health or developmental disability services in a program operated, licensed, certified, or funded by DHS (20 ILCS 1305/1-17) or of adults with mental, developmental or physical disabilities that impair their ability to seek assistance and whom reside in domestic settings (20 ILCS 2435/5). OIG is committed to conducting timely and thorough investigations.

A. Investigative Timeliness

Rule 50 states that investigative case reports are to be submitted within 60 working days from assignment, unless extenuating circumstances prevent it. One such circumstance preventing completion within 60 days is an ongoing criminal investigation. When the Illinois State Police (ISP) accepts an allegation for criminal investigation, OIG is prohibited from beginning its administrative investigation. If the criminal investigation results in a referral for prosecution, OIG is often prohibited from beginning until the State's Attorney makes a prosecutorial decision.

Thus, OIG counts total time and OIG time separately (see Table 6 and 6a below). OIG has completed its Rule 50 investigations within the regulatory standard of 60 working days. Rule 51 cases were completed in an average of 24 days. Average time to completion of Rule 51 cases are not affected by ISP investigations. In FY2012, the average total days for completion of all investigations decreased by 9% even though the number of cases completed increased by 11% from FY2011.

Table 6: Average Time to Completion for All OIG Investigations, by Fiscal Year

Investigations

FY2007

FY2008

FY2009

FY2010

FY2011

FY2012

Number completed

2,494

2,744

2,866

2,840

3,070

3,420

Average total days*

44.3

40.8

37.7

39.9

52.2

48.0

Average OIG days*

42.6

39.1

36.6

38.0

50.2

45.9

*Average total days includes all time from initial report until case closure; while average OIG days

omits time for delays necessitated by pending Illinois State Police investigations. This only refers to Rule 50 investigations.

Table 6a: Average Time to Completion for Rule 50 and Rule 51 Investigations

FY2012 Investigations

Rule 50

Rule 51

All

Number completed

2,480

940

3,420

Average total days*

57.1

24

48.0

Average OIG days*

54.2

24

45.9

*Average total days includes all time from initial report until case closure; while average OIG days

omits time for delays necessitated by pending Illinois State Police investigations. This only refers to Rule 50 investigations.

B. FY2012 Closures

By law, OIG uses three findings for its case reports. For Rule 50 cases, "Substantiated" means there is a preponderance of evidence that supports the allegation- that it is more likely true than not that the abuse or neglect occurred. "Unsubstantiated" means there is not a preponderance of evidence that supports the allegation. "Unfounded" cases have no credible evidence supporting the allegation.

In Rule 51 cases, abuse or neglect may be substantiated by a "reason to believe" abuse or neglect has occurred. Substantiated cases in domestic settings are not reported to the IDPH's Healthcare Worker Registry.

The findings in abuse/neglect allegations and in death cases OIG closed during FY2012 are presented in the three tables that follow. The column entitled "Other issue(s) only" shows cases in which OIG did not substantiate abuse/neglect, but identified an issue or issues and recommended that the facility or agency take administrative action to address it (unfounded with issues and unsubstantiated with issues). The column entitled "Not substantiated" shows cases determined to be unfounded with no issues and unsubstantiated with no issues.

Table 7a: Cases Closed in FY2012, Mental Health Services Only

Location

Abuse substan-tiated

Neglect substan-tiated

Other issue(s) only

Not substan-tiated

Allegation findings totals

Closed death cases

Facilities:

Alton MHC (civil) 1

1

1

1

51

54

0

Alton (forensic) 2

1

1

2

55

59

0

Chester MHC (forensic)

2

0

4

119

125

4

Chicago-Read MHC

2

1

4

11

18

2

Choate MHC

1

0

0

67

68

1

Elgin MHC (civil)

1

0

0

19

20

1

Elgin (forensic)

0

0

5

32

37

1

Madden MHC

0

0

2

29

31

0

McFarland MHC (civil)

1

1

1

21

24

0

McFarland (forensic)

0

0

1

7

8

0

Singer MHC

0

0

0

16

16

0

Tinley Park MHC

0

0

3

10

13

0

Facility subtotals

9

4

23

437

473

9

Community agencies:

Residential

5

3

20

47

75

19

Non-Residential

8

0

7

29

44

2

Agency subtotals

13

3

27

76

119

21

Rule 50 MH Totals

22

7

50

512

591

30

1 Civil units are for those individuals not committed by criminal court order.

2 Forensic units are for those individuals who are committed by a criminal court order.

Table 7b: Cases Closed in FY2012, Developmental Services Only

Location

Abuse substan-tiated

Neglect substan-tiated

Other issue only

Not substan-tiated

Allegation findings totals

Closed death cases

Facilities:

Choate DC

2

4

8

41

55

3

Fox DC

1

1

0

10

12

2

Jacksonville DC

4

4

6

55

69

2

Kiley DC

3

5

6

14

28

0

Ludeman DC

1

2

13

36

52

4

Mabley DC

2

2

2

8

14

1

Murray DC

1

4

4

26

35

3

Shapiro DC

5

0

1

31

37

2

Facility totals

19

22

40

221

302

17

Community agencies:

Residential

103

114

280

668

1,165

110

Non-Residential

37

35

85

242

399

8

Agency totals

140

149

365

910

1,564

118

Rule 50 DD Totals

159

171

405

1,131

1,866

135

Table 7c: Cases Closed in FY2012, Domestic Settings Only

Location

Abuse substan-tiated

Neglect substan-tiated

Exploitation substan- tiated

Refused consent*

Not substan- tiated

Findings Totals

Developmental disability

68

50

1

140

376

635

Mental health

2

2

0

49

52

105

Physical disability

7

5

2

66

121

201

Rule 51 Totals

77

57

3

255

549

941

The statute governing OIG's duties and responsibilities in domestic settings allows an alleged victim to refuse consent for the assessment or services. That is, in 255 domestic cases above, the alleged victim did not consent to OIG conducting an assessment of whether abuse or neglect occurred.

Trends in Closures

OIG continues to strive to keep up with the increase in allegations received. During FY2012, OIG closed 3,398 allegations compared to the 3,463 new allegations received. Counting the 165 closed death cases, OIG closed a total of 3,563 cases.

The continuing increase in allegations closed has been significant. During FY2012, OIG closed 11% more allegations than FY2011 and 18% more than in FY2010. While investigative caseloads are increasing, OIG continues to seek out improved efficiencies and streamlining of internal processes.

Trends in Investigative Findings

The substantiation rates - the percentage of allegations that are substantiated - over the past eight years are shown in Table 8 below. The rate of substantiations has fluctuated slightly over time, but the trend is stable and consistent.

C. Reconsiderations

During FY2012, OIG received 138 requests to reconsider the findings of an OIG investigation under Rule 50, these 138 requests pertained to the findings of 120 investigations. Of the 138 requests during FY2012, OIG granted 30 (involving 25 cases); the remaining 108 requests were denied because they provided no new information. Of the 25 cases with granted reconsiderations, OIG revised 17 case reports. Of the 17 revised case reports, 11 had changes in findings or issues. OIG received requests for reconsideration in approximately 33% of all Rule 50 substantiated cases. The reconsideration process continues to show that OIG investigative findings are largely accurate and that OIG is responsive to new information that can change the finding.

Chapter IV: Stopping Abuse/Neglect

OIG's statutory mission goes beyond investigating. As noted at the outset of this report, OIG has been given responsibilities to act to prevent abuse and neglect from occurring. Further, the statutes require that OIG act to help stop abuse and neglect when it is happening. This role is evident in emergency interventions in domestic abuse/neglect; in the identification of site visit issues each year; in recommendations to eliminate problems that may lead to recurrent abuse and/or neglect; and in tracking and ensuring compliance with actions taken in response to those recommendations.

A. Domestic Abuse Intervention

OIG continues to have separate statutory authority to take immediate action to intervene in domestic situations where abuse, neglect, or financial exploitation is being substantiated or will be substantiated (20 ILCS 2435/5). The statute describes three primary interventions in domestic cases: Emergency placement in a different residence; a formal order of protection obtained through local court system; and initiation or a change of guardianship, either to a different family member or the Office of State Guardian.

Emergency Placement

The most common type of emergency intervention is the removal of the individual from a situation where there is risk of injury or death. Upon investigating an allegation, OIG may find an individual in imminent risk - i.e., a serious, life-threatening medical condition which requires emergency transport to a hospital or other medical facility.

When the individual's immediate medical condition is not life-threatening, but OIG finds a risk of ongoing abuse or neglect, OIG may ask the individual if he/she would like to move. If the individual agrees, OIG may facilitate his/her move to a different residence on an emergency basis. This may be done after some initial investigation into the situation reveals significant risks not immediately known.

Order of Protection

OIG may instead find that the problem is the alleged perpetrator, not the individual's home. OIG may help the individual pursue an Order of Protection against the alleged perpetrator. Since this intervention is time-limited and requires the cooperation of the alleged victim, it is used infrequently.

Guardianship

If the alleged perpetrator is also the individual's guardian, and the evidence indicates there is an immediate and urgent necessity, OIG may seek the appointment of a temporary substitute guardian. OIG first tries to find a suitable family member to assume guardianship. If that fails, OIG discusses the case with the Illinois Guardianship and Advocacy Commission, Office of State Guardian. If that Office agrees to accept the case, OIG then petitions the court to appoint a person from Guardianship and Advocacy as the guardian. This intervention has long-term benefits for care and treatment decisions, so it is much more frequently used.

Table 9 below shows the break-out of emergency interventions during FY2012 and the prior six fiscal years. While variations from year to year can be significant, no long-term trends in these interventions are apparent. The use of emergency placement increased by 35% since FY2011 and FY2012 was the highest in the past seven years.

FY2012 service plan referrals

When OIG substantiates a domestic case, the statute requires that OIG refer the individual to the appropriate DHS program division to develop a plan for providing needed services. Individuals referred may already be receiving services provided by DHS either directly or through a community agency. Table 10 on the following page shows the program divisions to which OIG referred individuals in substantiated cases during FY2012 and the six prior fiscal years.

Most service plan referrals continue to be to the Division of Developmental Disabilities. In addition to service plan referrals, OIG may make a secondary referral to another division or external entity. Counting the secondary referrals, OIG made 255 referrals in substantiated domestic cases.

B. Health Care Worker Registry

The Health Care Worker Registry, maintained by the Department of Public Health (DPH), reports training information for certified nursing assistants (CNA) and other health care workers, as well as administrative findings against employees under the jurisdiction of OIG. The Department of Public Health also lists its own administrative findings of abuse and neglect for any employee on the Registry deemed trained and qualified by DPH. Since January 1, 2002, OIG has been required to notify the Registry of the identity of any person substantiated to have committed physical abuse, sexual abuse, or egregious neglect in a Rule 50 setting. AEmployee,@ by statutory definition, has been expanded and now includes, but is not limited to: Owners, operators, payroll personnel, contractors, subcontractors, and volunteers. It also includes someone who is no longer working for an agency or facility, but is the subject of an ongoing OIG investigation.

Data and Trends in Registry Referrals

FY2012 is the tenth full year in which employee names were referred to the Health Care Worker Registry. During FY2012, OIG made 64 referrals to the Registry. Seven referrals involved facility employees and 57 involved agency employees. One staff was referred for three cases, one was referred for two cases, and four employees were referred for both physical abuse and egregious neglect.

During FY2012, all seven facility employees referred to the Registry were direct care staff. Two of the 57 agency staff referred this year were administrative, one was a residential administrator referred for egregious neglect and the other was a house manager referred for physical abuse. The other 55 agency staff were direct care staff.

Type of Referrals

Physical Abuse: Most Registry referrals are due to physical abuse cases where staff became angry or lost patience with individuals due to real or perceived non-compliance with programs.

Substantiated physical abuse accounted for 46 of the 64 referrals (72%) this fiscal year - six facility staff and 40 agency staff.

Among referrals for physical abuse in FY2012 were the following.

An agency employee, who had a history of "horseplay" and teasing an individual, became too rough and spanked him with a spoon; this caused red, raised welt marks across the individual's buttocks.

An employee became "bored" and decided to ram two wheelchair-bound individuals with another wheelchair. Three weeks later, the same employee entered a classroom, slapped one of the same individuals across both sides of his face saying, "Ah, that's better." He then sat in a wheelchair and rammed the individual five times, hitting him in the face with his boots as he did it. He continued even after another staff member repeatedly told him to stop what he was doing.

An employee struck an individual in the face, resulting in two fractures to his mandible, requiring surgery to repair. The employee was found guilty of criminal abuse to a disabled person, a Class 3 Felony. He was sentenced to 90 days in jail, fined $500.00, ordered to serve two hundred hours of community service, and placed on thirty months' probation.

Two employees bound an individual's hands and ankles with duct tape, covered her head with a blanket, and left her on the kitchen floor of a CILA for several hours. Two other individuals observed this and one of the employees called them several times and they threatened them to remain silent. The employees then hid the evidence of scissors, tape, and sweat clothing with tape residue.

Sexual Abuse: In FY 2012, seven employees were referred to the Registry for sexual abuse. Four were DD agency employees, two were MH agency employees, and one was a DD facility employee.

Among this year's referrals for sexual abuse were the following:

A DD facility employee had three substantiated cases of sexual abuse, after he asked three different individuals questions of a sexual nature, he was observed lying on top of and "humping" them on three separate occasions.

A MH employee had ongoing sexual relations for five months with an individual and repeatedly borrowed money from her and her boyfriend.

Egregious Neglect: In FY2012, eleven names were referred to the Registry for egregious neglect. This number included six individual deaths and two cases in which individuals were extensively burned due to lack of adequate supervision. Among the cases were:

Three employees savagely assaulted an individual and also directed several of the victim's housemates to assault him. During the attack, he was body slammed onto the ground, hit and kicked in the head. When he passed out, staff members unsuccessfully attempted to revive him for approximately one hour and even traveled to local stores to find smelling salts to accomplish this, without seeking medical attention. When they finally contacted a supervisor, they did not relay the extent of the injuries, so 9-1-1 was not called and an ambulance did not arrive until almost two and a half hours after the incident. The individual passed away eight days later and an autopsy determined that he died of pneumonia due to head injuries. Two of the housemates involved in the assault were charged and convicted of aggravated battery and two of the three staff members were charged with murder and criminal neglect of a dependent. The third employee was charged with obstruction of justice. Four of the five either pled or were found guilty of their charges and sentenced; the last is awaiting trial.

An individual accused of stealing food was "punished" by an employee, who forced him to hold heavy books in his outstretched arms. When the individual dropped the books, the employee forcibly pushed him into a doorjamb and then into a coffee table. He then hit and kicked the individual in the chest, ribs, upper arms, abdomen, flanks, groin, scrotum, right knee, and spine for approximately 15 minutes, while another employee also kicked him and did nothing to stop the attack. Neither reported the beating, so his injuries were not discovered until the next day, and a series of events including obstruction resulted in delay of medical attention until three hours after that. The individual died of multiple rib fractures four days later, and the manner of death was ruled a homicide. One employee was convicted of aggravated involuntary manslaughter and sentenced to eight years in prison. The other was convicted of Criminal Neglect of an Individual and Obstruction of Justice and sentenced to four years and three years, respectively, both sentences to be served concurrently.

C. Written Responses

When OIG substantiates abuse/neglect or makes a recommendation regarding other administrative issues during an investigation, the facility or agency is required to respond in writing. This "Written Response" must indicate the action(s) that have been taken or are planned to protect the individual from future occurrences of abuse/neglect and eliminate the problem(s) identified during the investigation.

The facility or agency has 30 calendar days from the date the investigative report is received to submit a Written Response to the appropriate program division in DHS. The program division then reviews and approves the Written Response, listing the proposed actions, sending the approved Written Response to OIG.

During FY2012, OIG sent to the facilities or community agencies an initial Written Response in 842 cases; that is, OIG made a finding and/or at least one recommendation in 842 cases during the fiscal year. This is 10% more than the 765 required during FY2011 and 14% more than the 739 required during cases in FY2010.

FY2012 Issues

During FY2012, OIG received the approved Written Responses in 828 of those 842 cases. OIG also received 66 that had been required during a prior fiscal year, totaling 894 approved Written Responses received during FY2012. Those 894 Written Responses identified a combined total of 1,326 issues. Table 12 on the following page compares the number of issues cited across the prior three fiscal years.

This table shows that the counts of total issues OIG cited and of total substantiations by OIG were significantly higher during FY2012 than in the approved Written Responses received the previous year. In FY2012, substantiations accounted for 30.1% of the issues cited.

Late reporting has been identified and cited more this year than the prior two years: 196 versus 181 during last year. Failure to report was cited 177 times, which is double last year's total.

Investigative errors by facility or community agency staff after an allegation is made - such as failure to obtain an immediate medical examination or to take a photograph of an injury site - are decreasing. OIG attributes part of the decrease to its mandated biennial investigative training required of facility and agency investigators.

FY2012 Actions Taken

OIG may identify multiple issues in a single case, and each issue may require multiple actions. Any single action may involve many people (e.g., a group training of ten employees) or many documents (e.g., a revision of three related forms). For consistency of reporting, OIG counts actions taken.

During FY2012, the facilities and agencies performed 1,951 actions (a 28% increase from FY2011) to address the 1,326 issues (a 12% increase from FY2011) identified in the 894 cases with an approved Written Response.

OIG categorizes the actions taken into 22 types. During FY2012, the most common action taken continues to be retraining of the involved employee(s), which was completed in 430 issues that were raised in approved Written Responses. Related to this is general group retraining, which may involve a single unit, a job function, a range of job titles, or the entire staff of the facility or agency, which was completed in a total of 207 issues.

After training, the most common action is disciplinary action involving at least one employee: i.e., discharge (258); suspension (69); written reprimand (103); and oral reprimand (31). In addition, in 14 times at least one employee had been fired for other reasons; in 25 times at least one was reassigned; and in 94 times at least one employee resigned in lieu of disciplinary action. Counseling (80); increased supervision (nine); and performance evaluation objectives (one) were other actions taken with employees.

Policy or procedural revisions were made in 83 issues; modifications were made to habilitation or treatment plans in 83 issues; administrative changes were made in 27 issues; and some repairs/upgrades to buildings and other structures were completed in three issues.

FY2012 Implementation Status Reports

As noted, OIG investigations continue to cite administrative issues, resulting in significant actions by the facilities and community agencies to prevent recurrence and to eliminate problems. While the DHS program divisions are required to review and approve those actions, the statute gives OIG the responsibility to ensure that those actions are implemented. OIG does this in two ways.

One way is that the facility or community agency must list on the Written Response the date that all actions were implemented. If all actions were not implemented by the time the Written Response was approved, the facility or community agency must send an implementation status report to OIG every 60 days until every listed action is implemented. On a monthly basis, OIG sends the facility or community agency a reminder letter about any implementation status reports that are overdue. The letter also indicates what is needed on the case(s).

FY2012 Compliance Reviews

The other way that OIG ensures that the actions are implemented is through obtaining actual documentation proving that implementation. These "Compliance Reviews" are discussed in Rule 50.80 (d).

OIG conducts Compliance Reviews on two types of Written Responses. First, each month, OIG selects a random sample of all approved Written Responses received during the prior month - Rule 50 requires a minimum of 10%; OIG chooses 15%. Second, each month, OIG adds to that sample every approved Written Response that has been approved for longer than 120 days, but for which the actions listed on it have not yet been implemented.

For FY2012 Compliance Reviews, OIG randomly selected 155 (17.2%) of the 899 required Written Responses approved from May 1, 2011 through April 30, 2012, and then added the remaining 26 unselected Written Responses that were pending over 120 days. Table 13 below shows the break-out of all 181 Compliance Reviews by disability type and location.

Table 13: FY2012 Compliance Reviews on Approved Written Responses

Location

DD Programs

MH Programs

Totals

DHS facilities

26

11

37

Community agencies

140

4

144

Totals

166

15

181

OIG's Compliance Reviews seek documentation that the actions listed in the approved Written Response were actually taken. For example, in the cases of retraining for late reporting, the Compliance Reviewers first obtain training sign-in sheets or some other document proving completion of the training and then, either interview the employee to ensure that he or she knows the definitions of abuse and neglect and knows the process and time frames for reporting allegations or obtains a signed acknowledgment or successfully completed test. The Compliance Reviewers may also review the curriculum for the training and recommend using the OIG Rule 50 training module that was distributed in April 2010.

During FY2012, OIG sent nine "out of compliance" letters - that is, in nine compliance reviews, the facility or community agency did not provide documentation that all actions listed on the approved Written Response had been implemented. Seven were at DD community agencies, and two were at facilities (Elgin and Choate).

OIG's randomly selected compliance reviews help ensure that problems and unsafe practices identified during an investigation have been corrected by the facility or agency. Ensuring that corrective action has been taken helps the facility and agency to effectively address the underlying issues and allows the individuals to avoid suffering a recurrence of the abuse/neglect. It also brings OIG full-circle in preventing abuse/neglect of people in Illinois that are receiving mental health or developmental disability services.